2. Name of Contractor
4. Address
6. City
7. State
8. Zip
10. Telephone:
12. Principal Officer:
14. When organized:
15. If a Corporation, where incorporated:
17. General character of work performed by company:
19. Has the company ever failed to complete any work awarded to it? If so, where and why:
21. Has the company ever defaulted on a contract? Is so, where and why:
23. Has the company ever been cited for violation of Equal Opportunity hiring laws of either the State of Ohio or the U.S. Government? If so, where and why?
25. Is the company presently on any "disbarment" list of any Federal agency?
27. Do you carry liability insurance on both persons and property?
29. Amount: $
30. Amount: $
32. Are your employees covered by workers compensation?
34. Have you ever been bonded for job performance?
35. Have you ever forfeited on a performance bond?
37. List the more important projects recetly completed by the company, stating the approximate cost for each and the month and year completed:
39. Work References:
41. Supplies references:
43. Insurance or bonding references:
45. Sub-contrators references:
47. Bank references:
49. Credit available in dollars:
51. General background, such as experience of co-workers, including officers, and other information showing ability to work in rehabilitation property improvement construction:
53. The undersigned hereby authoizes and requests any person, firm, or coporation to furnish the information requested by the City of Lancaster's Community Development Department for verification of the information contained in this statement of contractor's qualifications.
55. Contrator's Name & Title:
57. By:
58. Title:
60. Date:
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field